Managing Medications

and

Side Effects

Deborah Olin Heros, MD

Neuro-Oncology

Department of Neurology

University of Miami Miller School of Medicine

Sylvester Cancer Center

Quality of Life

Physical * Cognitive * Emotional

Understanding the Symptoms of Your Tumor and Treatment

* Symptoms as the result of tumor location

* Symptoms related to increased intracranial pressure (ICP)

* Symptoms related to treatment

- Surgery

- Radiotherapy

- Chemotherapy

- Medication

• Unrelated Condition

Symptom ManagementSeizures

Who needs to be on an anticonvulsant medication?

• Risk dependent upon type and location of tumor

•Overall risk 25-40%

* Use of anticonvulsant

- Compliance, monitoring levels

* Factors altering seizure threshold – Increasing risk for seizure

•Sub therapeutic levels / Noncompliance

•Fever/ Infection

•Lack of sleep

•Missing meals

•Stress

•Alcohol

•Menses

•New medications / Medication interactions

SeizuresSeizuresAcute ManagementAcute Management

* * Seizure precautionsSeizure precautions

- - Use good judgment: do not put yourself in situation such that if you Use good judgment: do not put yourself in situation such that if you

suffered a seizure, you could hurt yourself.suffered a seizure, you could hurt yourself.

Acute managementAcute management

Assistance and protectionAssistance and protection

AirwayAirway

MedicationsMedications

When to call 911When to call 911

Know your state laws regarding seizures and driving!Know your state laws regarding seizures and driving!

Choosing an Anticonvulsant Choosing an Anticonvulsant MedicationMedication

How does your physician choose an How does your physician choose an anticonvulsant medication?anticonvulsant medication? Acute management for seizureAcute management for seizure Preparation for surgeryPreparation for surgery Type of seizure (focal vs generalized )Type of seizure (focal vs generalized ) ProphylaxisProphylaxis Route of administration ( p.o. or i.v. )Route of administration ( p.o. or i.v. ) Side-effect profileSide-effect profile Drug interactionsDrug interactions

• Liver enzyme-inducing meds and chemotherapyLiver enzyme-inducing meds and chemotherapy

AnticonvulsantsAnticonvulsants

Dilantin ( phenytoin)Dilantin ( phenytoin) Brand name vs. genericBrand name vs. generic Side-effectsSide-effects

• Rash Allergy: Stop immediatelyRash Allergy: Stop immediately• Dizziness, staggering, clumsinessDizziness, staggering, clumsiness• Sleepiness, confusionSleepiness, confusion• Blood abnormalitiesBlood abnormalities• Gum swelling/bleedingGum swelling/bleeding• Chronic: OsteoporosisChronic: Osteoporosis

Available as oral or i.v. formAvailable as oral or i.v. form

Tegretol (carbamazepine)

•Brand name vs generic

•Side-effects

- dizziness, unsteady gait

- sleepiness

- blood abnormalities

•Monitor blood levels

•Oral form only

Depakote (valproic acid)

- somnolence

- weight gain

- upset stomach, nausea

- blood abnormalities

• - monitor blood levels

-Available in oral and i.v. form

Topamax (topiramate)

• Need to start gradually• Side-effects

• Weight loss• Memory impairment

• Also helpful to prevent migraines

• Oral form only

Keppra (Levetiracetam)Keppra (Levetiracetam) Doses 1000-3000 mgs/day in twice daily dosingDoses 1000-3000 mgs/day in twice daily dosing Side-effectsSide-effects

• DizzinessDizziness• SomnolenceSomnolence• Personality changesPersonality changes

Does not induce liver enzymesDoes not induce liver enzymes Not approved as single agent for generalized seizuresNot approved as single agent for generalized seizures Levels now availableLevels now available

Available in oral and i.v. formAvailable in oral and i.v. form

Lamictal (Lamotrigine)Lamictal (Lamotrigine) Needs to be started graduallyNeeds to be started gradually Side-effectsSide-effects

• RashRash• Does not induce liver enzymesDoes not induce liver enzymes

Levels now availableLevels now available

Oral form onlyOral form only

Neurontin (gabapentin)

- drowsiness

Oral form only

Phenobarbital- sleepiness, sluggishness

- depression

Available in oral and i.v. formAvailable in oral and i.v. form

AnticonvulsantsAnticonvulsants

Dilantin® (phenytonin) Lamictal® (lamotrigine)

Luminal® (phenobarbital) Tranxene® (clorazepate)

Tegretol® (carbamazapine) Valium® (diazepam)

Depakote® (valproic acid) -suppository available as Diastat

Neurontin® (gabapentin) Ativan® (lorazepam)

Trileptal® (oxcarbazepine) Klonopin® (clonazepam)

Topamax® (topiramate) Lyrica® (pregabalin)

Headaches

- May be a sign of increased pressure either from tumor growth or effects of treatment

- Monitor persistence and pattern

- May occur if steroid tapered too quickly

Headaches that awaken from sleep or are worse upon arising in a.m. are often due to pressure.

- Treatment: dexamethasone

Increasing Neurologic DeficitsIncreasing Neurologic Deficits

- May be a sign of increased pressure either from tumor growth or effects of treatment

- May occur if steroid tapered too quickly

- Acute: bleeding a possible cause

- May be transient and related to fatigue or seizure

Increasing SomnolenceIncreasing SomnolenceMany Causes:

- increased pressure dexamethasone or appropriate therapy

- anticonvulsant medications (check levels, adjust)

- other medications (review with physician)

- seizures (observe for seizure activity, check levels)

- infection (look for source)

- abnormal blood studies

glucose (dexamethasone) ↑

Na (sodium) ↓

AnxietyAnxiety

- often due to or worsened by steroids

- component may be “ situational”

- treated with Xanax®, Ativan®, or antidepressant medication

Anti-anxiety agents:

Xanax® (alprazolam) Tranxene® ( clorazepate)

Ativan® (lorazepam) Paxil® ( paroxetine)

Klonopin® (clonazepam)

DepressionDepression

- may be “organic” as a result of tumor / treatment

- reactive, situational component

- “ Emotional lability”

- personality changes

- treat with antidepressant medication

Anti-Depressants:

Zoloft® (sertraline) Celexa® (citalopram)

Paxil® (paroxetine)

Personality ChangesPersonality Changes

Location of tumorLocation of tumor MedicationsMedications

DexamethasoneDexamethasone AnticonvulsantsAnticonvulsants

• KeppraKeppra®®• LyricaLyrica®®

FatiqueFatique- may be related to medication or associated with radiation therapy

- may occur during dexamethasone taper

- check hormone levels (yearly beginning 1 year after radiotherapy)

Stimulants:

Dexamethasone

Zoloft® (sertraline)

Ritalin® (methylphenidate)

Dexedrine® (dextroamphetamine)

Provigil® (modafinil)

Adderall® (dextroamphetamine & racemic amphetamine)

InsomniaInsomnia- most often result of dexamethasone (avoid PM dose)

(change dose, timing)

- sleep-wake cycle may be altered

( use stimulating medication in the day, sedating medication at night)

- Medication may be helpful

- Benzodiazipine

- Antidepressant

DexamethasoneThe most effective treatment for increased intracranial pressure

- timing and dose of medication

- Side Effects

anxiety, irritability, depression, mood lability

insomnia

* Avoid evening dosing

increased appetite

elevation of blood sugar (diabetes mellitus)

muscle wasting (myopathy)

skin fragility (bruising)

* Skin protection

DexamethasoneDexamethasone

Stomach ulcers and increased acid secretion

* Take with food, use medicine to protect your stomach

* Report symptoms of pain to your doctor

Stomach Protectants

Zantac® (ranitidine) Prilosec® (omeprazole)

Pepcid® (famotidine) Nexium® (esomeprazole)

Tagamet® (cimetidine) Protonix® (pantoprazole)

Prevacid® (lansoprazole) Aciphex® (rabeprazole)

Antacids (eg. Maalox, Tums)

DexamethasoneDexamethasone

* Change in appearance (“cushinoid appearance”)

* Osteoporosis

* Joint pain “arthritis-like” with taper

* Never stop suddenly

* Rate of taper determined by original dose, amount of swelling present, and duration of steroid therapy. Therefore, the higher the dose and the longer you have been on steroids, the slower taper.

Quality of LifeQuality of LifeOptimizeOptimize medications and medications and MinimizeMinimize Toxicity Toxicity

Be InformedBe Informed

Communicate with Health Care TeamCommunicate with Health Care Team

ComplianceCompliance